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SAN JOAQIJ`!1COUNTY ENVIRONMENTAL NEALTOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .LA- 6 oc)&3 �' ,5 eoo (,o-72_Co <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Kwik Sery-Tracy <br /> SITE ADDRESS 950W 111th Tracy 95376 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209 ) 832-1810 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl Wayne Henderson CHECK if BILLING ADDRESS <br /> BUSINESS NAME HMC- Henderson Maintenance Company PHONE# EXT. <br /> 209 467-7573 <br /> HOME or MAILING ADDRESS FAX# <br /> PO Box 31325 (209 ) 465-4988 <br /> CITY Stockton STATE CA Zip 95213 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:Com( ,__- �jl`� DATE: 8/5/10 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Contractor <br /> ff,4PPL,CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Tank Retrofit <br /> COMMENTS: Replace diesel annular space sensor <br /> Gousv <br /> SANEN�IR�NME SENT <br /> H�TM pEPAR <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: L EMPLOYEE M DATE: <br /> Date Service Completed (if alre completed): SERVICE CODE: 1 P 1 E. <br /> Fee Amount: D" Amount Paid 3� Payment Date S O <br /> Payment Type ✓ Invoice# Check# 1 /I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />